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Prior Auth for Iowa Total Care

Friday, July 12, 2019   (0 Comments)
Posted by: Carl Lingen
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Iowa Total Care Prior Authorization 

Iowa Chiropractic Society has been working with our consultants to address the need to submit a prior authorization for every member with Iowa Total Care.

ICS does not agree with Iowa Total Care's decision and we are working on a policy and legislative front on your behalf. We are hopeful that Iowa Total Care follows the Iowa Medicaid Enterprise (IME) provider manual which states chiropractic coverage does not require prior authorization. 

Our Society has been working with our Medicaid and Medicare consultant, practice consultant, legal and legislative liaison team to address this issue with Iowa Total Care.

Please note, that currently Iowa Total Care is requiring a prior authorization. This information may change so please make sure you are following our e-newsletter. 

With the help of our Medicaid and Medicare Consultant, Dr. Sheybani, we have completed some questions and answers for you to assist in filling out the prior authorization successfully.












Question 1: What should we use as the end date on the prior authorization?

Answer: Considering there is a medical necessity for care, I recommend for providers to make the end date decision based on patient’s care plan, and Medicaid coverage category.

  • Category I diagnoses generally require short term treatment (12 manipulations per 12-month period).
  • Category II diagnoses generally require moderate term treatment (18 manipulations per 12-month period).
  • Category III diagnoses generally require longer term treatment (24 manipulations per 12-month period).
  • The utilization guideline for diagnostic combinations between categories is 28 manipulations per 12-month period.

Question 2: The prior authorization only allows for one diagnosis code to be entered, what should I enter for my patient?

Answer: Although subluxation diagnosis codes should be used as the primary code for Medicaid claims, I recommend using the highest complexity ICD-10-CM based on the list provided by IME.

Question 3: The prior authorization asks for additional clinical forms to be submitted or a decision could be denied or delayed. What, if any, documents should I provide?

Answer: Providing a copy of the radiology report from the plain film imaging, the care plan and a copy of the most recent evaluation and management (E/M). 

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